A new payer tactic: Using AI to curtail routine radiology claims, after imaging is already delivered
Advanced imaging services have long been in the crosshairs of insurers, but healthcare consultants are recommending a new tactic to further curb claims.
Services such as CT, MRI and PET are frequently subject to prior authorization, requiring a provider to obtain payer approval before care delivery. However, benefits consultants are urging insurers to turn their attention toward other more routine imaging exams such as X-rays, ultrasounds and noncardiac nuclear medicine.
“Because it’s more common and costs less per unit, routine tests are approved with little or no checking by plans as to whether they are consistent with or following best practice guidelines,” Mark Hiatt, MD, MBA, a Stanford University-trained radiologist and consultant with Tampa, Florida-based Avalon Healthcare Solutions, wrote for MedCity News June 11. “This oversight presents both a challenge and an opportunity for plans.”
Hiatt and co-author Jim Koger, MPH, Avalon VP of product, highlighted three potential examples of possible wasteful services. They included pre-op chest X-rays in healthy patients, duplicate or redundant exams, or overuse of bone-age studies. While much of routine imaging is low-ticket, their high volume “makes them a significant expenditure.”
Rather than going through the administrative burden of subjecting X-rays and ultrasounds to prior authorization, the two recommend a new approach. Plans could implement “post-service, prepayment automated management based on clinical guidelines.” This would involve using AI to evaluate already-submitted routine imaging claims against a set of national standards and health plan preferences.
“Unlike [prior authorization], this model does not delay patient care and does not hold members liable to pay for unneeded exams,” the authors wrote. “Denials are coded as provider liability, encouraging guideline adherence through feedback rather than disruption,” they added.
Hiatt and Koger noted that this “automated management model” also could provide claims decisions and education to referrers, who might be “more likely to adhere to policy guidelines when ordering routine imaging.” They estimate this would result in savings of up to $1 spent per member per month.
“As pressures mount on plans to control spending and members’ out-of-pocket expenses, while simultaneously improving care, it makes sense for them to reexamine areas that previously had gone unmanaged,” the piece concludes. “Given the volume of testing and the high incidence of nonadherence to plan policies, routine radiology is one of those areas.”
According to its website, Avalon already offers such a solution geared toward routine lab tests. In a social media post Thursday, Koger said he is “excited about this new product,” with the consulting firm now spreading the same service into routine imaging.
Hiatt previously was an attending cardiovascular radiologist with Christus Trinity Mother Frances Health System in Texas, according to LinkedIn. He later became executive medical director with Regence BlueCross BlueShield of Utah. The radiologist is now CMO of accreditation organization RadSite and CEO of his own consulting firm, Hiatt Advisory Services.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.